- Posted:Tuesday 27 March 2018
Do we expect too much – or too little – from the NHS? Should taxes increase to fix its problems? Helen McKenna talks about public satisfaction with the NHS with Ruth Robertson and Dan Wellings from The King’s Fund. Leo Ewbank gazes into his crystal ball to look at what’s coming up in health in the month ahead.
- Public satisfaction with the NHS and social care in 2017
- Public satisfaction with GP services drops to lowest level in 35 years
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- HM: Helen McKenna
- RR: Ruth Robertson
- DW: Dan Wellings
- LE: Leo Ewbank
HM: Hello and welcome to the first ever episode of The King’s Fund podcast. I’m Helen McKenna, Senior Policy Adviser at the Fund and each month we’ll be exploring interesting topics and ideas from the world of health and social care policy. To help us get under the skin of these issues, we’ll be joined by a range of expert guests from the Fund and beyond.
Coming up later in our first episode, we’ll be gazing into our crystal ball to see what’s happening in the month ahead, including finding out why the Department of Health has found itself in court. But first, this July, the NHS will turn 70 years old. As its official birthday approaches, we can expect to see even more debate than usual about how the NHS is doing and what its future should be. But what does the public think about the NHS? And crucially, how are their views changing?
To explore this, I’m joined by two King’s Fund Fellows: Ruth Robertson and Dan Welling. Ruth is involved in designing the health and social care questions that the public are asked, in NatCens British Social Attitudes Survey. NatCen, or the National Centre for Social Research, has run the survey for 35 years and each year they ask people about what it’s like to live in Britain including their views on the NHS.
Dan has a special interest in public perceptions of the NHS and is currently doing some research looking at the relationship between the NHS and the public and how it’s changing. Welcome to you both.
RR: Thanks Helen.
DW: Thanks Helen.
HM: So, Ruth, let’s start with you. The latest results of the British Attitudes Survey have recently been published. What does the public think about the NHS?
RR: Thanks Helen, yes, we’ve just published the results from 2017 and they show that public satisfaction with the NHS dropped by 6 percentage points to 57 per cent and at the same time dissatisfaction with the NHS jumped up to its highest level since 2008. Something I think is really interesting in these latest results is, we asked people, “Why? What do you mean when you tell us you’re dissatisfied with the NHS?” And the top reasons people give are all related to resourcing. So, they say, “The government aren’t spending enough money on the health service, there aren’t enough staff and waiting times are too long.”
HM: Do you think the public are right to worry about these sorts of issues?
RR: I think the health service is under huge pressure at the moment, it’s been going through a funding squeeze since 2010 and the impact of that is starting to filter through into public views. So, I think the public are picking up on the pressures that the health service has been under for some time now.
HM: So, funding has been squeezed since around 2010 and also performance against waiting times targets has been bad for some time, so why are we only now seeing an impact on public satisfaction?
RR: Yes, I think it’s an interesting question. We look at this data and we see in recent years that public satisfaction has remained quite high by historic standards, even though we know there’s huge pressures on the NHS in terms of funding and staffing. But I think it takes some time for that to filter through to the public.
Waiting times did hold up initially when the funding was first cut. It’s taken a while for the public to start to feel the effect of these resource pressures on their experience of care, but I think we’re starting to see that now and this year with the drop in satisfaction, I think the pressures are finally filtering through into public views.
DW: I’d agree with that. I think for this year we’re starting to see what we might call a tipping point, where you start to see that although the health community will be talking about some of the challenges that that NHS faces, it often takes some time for the public to realise what those are and to experience them and one of the questions around the satisfaction is, “What’s driving it?” Certainly, we can say that media coverage will be driving some of that, people’s own experience and what they’re hearing about the service. So, I think this year is a really interesting marker for where we are on the NHS, with this 6 per cent drop.
HM: Some people talk about his idea that the public’s expectation of the NHS is increasing. Are high levels of dissatisfaction just a matter of the public expecting too much of services?
DW: It’s certainly true that when you read many of the documents in the NHS, people talk about people’s expectations increasing, but one of the questions is actually, we’re starting to see in the qualitative work and in some of the polling we’re doing, people talk about these expectations that we get from the private sector and them seeping into our experience of the NHS.
Actually, we think it’s more complex than that, we have a very, very different relationship with the NHS and actually one of the hypotheses that we’re working on is, actually, “Do we expect enough of the service? Do we demand enough of it, or are we willing to accept a level of care which we wouldn’t accept in other areas of our life?”
And some of the work that Cambridge University and other have done around patient experience measures suggests that often we’ll give quite a high score to what the experience was, when actually when you judge that objectively through clinical investigators, it probably wasn’t the service that people wanted. So, this idea of expectations is really difficult to measure, but I don’t think it’s quite as clear cut as some of the statements that have gone around about this, about increasing expectations.
HM: Ruth said that the public are concerned about a lack of funding for the NHS. But the reality is that any extra money would need to come from somewhere. Would the public be willing to pay more tax to fix the problem?
DW: I think Ruth’s absolutely right, that what we’re stating to see is, this idea that there’s a funding issue in the NHS is becoming far more common and is more into pubic debate. So, if you look at many of the polls over the last year, which is one of the key things with the British Social Attitudes Survey, you don’t just look at one survey in isolation. You look at it alongside many of the other things that we’re asking the public about.
So, we wanted to look at this question last year, and one of the challenges with asking about taxes, is it’s very different to saying, “Yes, we think taxes should go up.” And someone actually meaning, their own taxes should go up. So last year we asked the question to try and answer the question you’re posing to me around, “Do you think people would be willing to put in more taxes?” And we asked it in two ways, one much more general about, “Do people think that taxes should increase?” They might not mean their own. And we also asked another part of the sample a more specific question about “Would they personally be willing to pay more taxes?”
And we asked both those questions in the same survey. So, what was really interesting from the findings it here was very little different between those two answers. So, we got 62 per cent saying “Yes, increase taxes.” But we actually got 66 per cent saying they would be personally willing to pay more tax.
Now that’s striking, that’s not statistically significant, between those two findings, but we’re finding across any of those questions that it’s two thirds of the population that are now starting to say they would be willing to pay more tax. Now, there’s a big difference between saying you would be wiling to pay more tax in a survey when someone asks you and the reality of actually having to pay that money.
But across all of these sources, that we’re seeing over the last year or so, you can see a big shift in public perceptions. On the British Social Attitudes Survey there are other questions aren’t there Ruth, around tax and spend? And we’re starting to see a difference. We’re starting to see an end to this idea that there’s just the signs of the ends of austerity and maybe people staring to entertain the idea that, “Maybe we need to pay more to get the services we want.”
RR: You’re right Dan, we’ve asked a question over the past few years asking the public whether they’d be willing to pay more tax if the NHS needs more money and we’re just looking at the latest results now. So, we’re going to be publishing them in April and I think it will be really interesting to see whether things have moved on and whether public attitudes on this are changing.
DW: One of the things Helen is that even when we see satisfaction shift significantly, so although the result has dropped this year, they’re not as low as they have been historically. In 1997 we only saw 34 per cent of people satisfied with the NHS, so we’ve been here before in terms of dropping off on public satisfaction. And one of the interesting things around this, is that as money came back into the NHS from about 2002 onwards, we started to see an upward shift in satisfaction. So, we’re at that debate now and you can see in many forums, whether it’s the politicians, whether it’s the media, this debate is starting play out, about “How do we pay for this service?”
HM: But Dan on the funding issue, do you think the public is starting to question whether the NHS funded via general taxation is the right model for the health service?
DW: I think it’s easy to look at when you see changes in satisfaction and think, “Well maybe that means people are questioning the model.” But the reality is that the model is the last thing to be questioned in most people’s mind. So again, we looked at this last year, and we wanted to see 70 years on as we hit the NHS’s 70th birthday, “Do the founding principles of the NHS still apply? Free at the point of need, comprehensive available to all and paid primarily through taxation.”
So, we tested those principles out. We might speculate that actually 70 years on they’re not as relevant as they were then, but actually we found that nine out of ten people, roughly on each of those, still strongly support them. The NHS, even within public service is an institution that receives support that nothing else in this country really does. One in two of us, say it’s the thing that makes us proudest to be British and sometimes we hear these statistics so often we forget their significance. That is an extraordinary finding.
HM: Do you think the public’s love of the NHS can sometimes get in the way of it doing proper reform?
DW: I think if you speak to people that have been involved in service change and service reconfiguration it’s often very difficult and our love of the NHS often means that we want to protect it. We often want to protect it against change and I think sometimes we might think that change is beneficial in the longer term but in the short-term people are very resistant to it actually being changed in any way
RR: And actually, when we asked people why they’re dissatisfied with the NHS, quite a large proportion of them told us it was about government reforms and that’s been an increase. So, over the past three years the proportion of dissatisfied people who are saying “It’s linked to government reforms,” went up from 20 to 32 per cent so I think this is a big issue for the public.
DW: I think Ruth’s findings on this are really interesting around the reasons for dissatisfaction. So, when you do qualitative works, whether it’s focus groups or deliberative work. In the past, there’s a piece of work that The King’s Fund did in 2012, when you talk to people about the NHS, there’s a perception that there’s lots of waste in the service. And one of the most striking findings for me from Ruth’s work, is that in 2017 we’ve seen a significant dropping off on the number of people saying, “Money is wasted in the NHS.” And I think it’s really interesting to see that shift. From before people thinking there’s lots of waste and we can see a dropping off of that among the public.
RR: I think that’s right Dan, that was one of the most interesting results this year. It feels like there’s a shift in public opinion. Their worries are less about what the NHS should do to tighten its belt, and more about what the government should do to provide more funding and staffing in the Health Service.
HM: I’d like to look at general practice. This year public satisfaction with GP services has slumped I think to the lowest level since the survey began 35 year ago. Do you know what’s behind this Ruth?
RR: You’re right Helen, I think this is one of the most concerning results in the survey this year. Satisfaction with general practice has been in decline since 2009 and this year for the first time, general practice is not the highest rated service amongst the public. So, what’s going on there? Well I think this is the public responding to the hue pressures on General practice. GPs are really struggling to meet growing demand from patients for their services.
We’ve got a growing number of people with complex chronic conditions that really need some in-depth care from GPs. We’re also seeing pressures in other parts of the system affecting general practice. So, the NHS is very connected and if District Nursing is under pressure, if district nurses are struggling to see their patients then that’s going to have a knock-on effect on the GP’s work load.
If patients are being discharged earlier out of hospital, into home in the community that’s fantastic but that creates extra work for GPs to treat them at home. So, I think GPs are really struggling to meet that demand and at the same time, we’ve got a workforce crisis in general practice. So, I was quite shocked looking at the workforce data on GPs, that at the end of 2017, there were fewer GPs working in the NHS than two years earlier and this is at a time when we’re trying to increase GP numbers to meet that growing demand.
DW: Yes, I think Ruth’s right on that. It’s important to look at other surveys or other sources, and the GP Patient Survey that Ruth referenced there, we hear from 800,000 people a year and over the last five years we’ve seen real drops particularly around access, around making an appointment. I think that would be a real concern for the government because if you thin about he NHS, that the vast majority of people’s interaction with the service is via a GP. So roughly eight out of ten people say they’ve had an appointment with a GP in the last twelve months. That’s why that finding in particular is quite striking as Ruth said, because that will be the thing that is worrying government right now.
HM: There is a lot of data out there on how the NHS is performing, such as waiting times data and funding data and the GP Patient Survey. How does public polling data from surveys like the British Social Attitudes Survey fit into this picture?
RR: Well I think the data in the British Social Attitudes survey is really important complement to that other performance data about the NHS. We’ve got 35 years of trend with this survey. So, policy makers can really look at the long-term impact of their approach to managing the health service, they can compare today’s views with not just views in previous years but views in previous decades as well.
So, I think this is a really key performance measure for the NHS, but like all data it needs to be viewed alongside other measures, measures of performance, measures of patient views. And I think what’s so powerful with the end at this year is what we’re being told by the survey, it fits with what we’re hearing form patient surveys, it fits with what we’re seeing in the waiting times data that targets are being missed and it fits with what we’re seeing in the funding data that shows that funding is being squeezed and trusts are really struggling to meet the financial demands that have been put on them.
HM: Dan, your last job was working for one of the national bodies at NHS England, so you have some inside knowledge. Do you have a feel for how much government and national bodies pay attention to this type of data? How worried do you think they’ll be by the latest results?
DW: I think it depends on the body that you’re talking about. Certainly, from my experience at NHS England, people will be looking particularly around the patient experience surveys and worrying about what people are actually getting and I think that’s the difference between something like the British Social Attitudes Survey and patient experience surveys and that’s relevant to who will be worried about that.
On the British Social Attitudes Survey from a government point of view they’ll be worried because in addition to people given their views on the NHS, they will be voting, and we know that the NHS is one of the key issues that people vote on. So, the more we start to see this drop in satisfaction, not just from this survey, but from a number of different sources, the more we can be certain that government will be more and more anxious about what it’s telling us.
HM: So, to wrap up I’m going to ask each of you, if there’s one message politicians and policy makers should take from what the public is saying right now about the NHS, as it approaches its 70th birthday, what would it be? Ruth, let's start with you?
RR: I think it would be that the public are worried about the NHS, and that the government needs to put more funding into the service if it wants it to meet future demands.
DW: I would echo that and say that actually again, if you look at other sources, this is measuring satisfaction at a point in time, the other piece of work that I certainly think is important is, when you look at pessimism for the future we’ve not got 62 per cent of people thinking it’s going to get worse. And again, that’s the importance of looking across a number of different data sources.
The final thing I’d say, Ipsos MORI, for many years have done something called The Issues Index, which judges, “Which is the most important issue facing the country right now?” And from the data in January, we saw the NHS is the number one issue for the majority of people, above Brexit which tells us something.
HM: Ruth Robertson and Dan Wellings, huge thanks for both of you for joining us today.
RR: Thanks Helen, it was great to talk to you.
DW: Thanks Helen.
HM: Now have you ever wished you could just gaze into the future of the health policy world? Well luckily for you, our podcast helps you do just that. Joining us with his crystal ball is Leo Ewbank, a researcher here at The King’s Fund who has had a look into the future and is going to let us know what to look out for over the next month or so. Welcome Leo.
LE: Hi Helen.
HM: So, tell us, what should we be looking out for in April?
LE: So, I think the first milestone is the beginning of the new financial year, that’s 2018-19 and this year, as with other years it comes with two separate components. So, to begin with the money, the health service is getting this year and additional £2.1 billion, the bulk of that from the Autumn Budget last year. And some of it found from within the Department Of Health budget. That translates into real terms growth of about 2.4 per cent which is more than some people were expecting, but as we and others have said, that is substantially less than the health service is used to receiving year on year and we don’t think on that financial settlement it’s realistic to expect the health service to meet rising demand, maintain quality and hit the access standards that we’re used to.
HM: We’ve just been talking about public satisfaction with the NHS, but from what you’ve said, it sounds like over the year ahead, we’re not going to see much improvement there, what do you think?
LE: I think that sounds right. I think if waiting times are an important driver of public satisfaction with the service, if we look at what’s expected of the service in 2018-19, I think there is general recognition now that the finance available doesn’t make it possible for the service to hit the standards that we’re used to, so patients will be waiting longer to receive care.
HM: Now, the NHS is pretty fond of acronyms, I gather there is a new one in town, Leo can you tell us?
LE: Yes, that’s absolutely right, there is a new three letter abbreviation in town, the ICSs or integrated care systems. These take the place of what were previously accountable care systems or ACSs. So, in terms of what ICSs are, they are groups of NHS providers and commissioner and in some cases local authorities coming together in an area to plan the provision of care and try and improve health and care of the population in their geographical area.
So, there are now ten places around the country that have secured this ICS designation. These range from Dorset down in the South West, up to Blackpool in the North West. There’ll be managing the money in a different way. So instead of each individual organisation needing to hit its own financial targets, what will matter is the collective financial performance of the ICS and that will translate into how they relate to the national regulators as well.
HM: So, this rebrand, what’s behind it? Are ICSs actually different to ACSs? Or is it purely a name change?
LE: So, I don’t think the name change should be seen as some great philosophical move. Accountable care is absolutely about delivering more integrated health and care services for the population. I think to understand why this has happened, we nee to look at what’s happened to ACOs, accountable care organisation which is a separate but related development and in short the government has brought forward a contract to enable their emergence within the NHS and this has caused some real political concern, and I think that is leading to concern among national leaders about the need to put clear blue water between the accountable care systems developments and what’s going on with the ACO Contract.
The ACO Contract has now been the subject of two separate judicial reviews. One focusing on the payment model which is embedded within it and another which particularly focuses on concerns about the ACO contract potentially creating additional space for private companies to be involved in the delivery of services. So, I think it’s that, which is driving the change from ACS to ICS, rather than any change in the substance of the agenda.
HM: But just to clarify on the judicial review, that means that we’ll see the Department of Health answering for ACO contracts in court. What happens if they lose?
LE: Yes, that’s absolutely right. So, these two cases will be coming to court in April and May 2018 and if the Department were to lose one of them, I think that will introduce delay into the process. The Department would need to go back and rethink how we’ve got to this point. But it’s worth making the point that the ACO contract is a separate thing to what is going on in the ICSs and the objective of bringing providers and commissioners together to provide more integrated care, is going to keep going regardless of what happens in the debate about the ACO contract.
HM: Well, it will be interesting to see how that all pans out. Thanks Leo.
LE: Pleasure, thanks.
HM: Well that’s it from us, with a big thanks to all of you for listening, as well as to our guests Dan Wellings, Ruth Robertson and Leo Ewbank. We’d love to hear from you, so if you have any feedback on what you’ve heard today or thoughts about the podcast, please get in touch via our website. www.kingsfund.org.uk or via Twitter either @thekingsfund or to me directly @HelenaMacarena. If you’ve enjoyed this episode, please subscribe, share it with your friends and join us for our next episode in a months’ time, see you then.
We have just published a report in Westminster on the outcome of a scrutiny review of health and well being - from which it is clear that our expectations of the 'NHS' have dramatically changed since inception in 1948 (a local doctor + acute treatment service) to a whole series of conditions not merely related to immediate medical treatments (e.g. chronic / life threatening conditions / mental health / learning disability / age related (deteriorations in personal circumstances). Do we now need a national debate to promote a new NHS conceptual framework - equal access to variable strands of care and treatments - Identifying infectious disease outbreaks, prevention, conditions at birth, personal lifestyle abuses - that may require state intervention free at the point of use?
As a past Deputy Chair of an acute NHS Trust, I follow the King’s Fund reports with interest.
I am shocked at this time to see how fast the performance of the NHS is falling, as evidenced by my own experience of both primary and secondary care, and how fast morale in the servicevitself is starting to follow. Our care provision is dropping towards being a second rate service. I strongly support the urgent need for cross party action to decide how best to turn this round as a matter of national urgency.